Albany, New York: (518) 438-0505

Medical History Form

Patient Name:
Primary Care Physician:
Date:

Allergies:
Hospitalization / Surgeries:

Medical Conditions

High Blood Pressure: Yes    No
Heart Murmur: Yes    No
Mitral Valve Prolapse: Yes    No
Heart Bypass Surgery: Yes    No
Heart Attack: Yes    No
Pacemaker: Yes    No
Asthma: Yes    No
Stroke: Yes    No
Diabetes: Yes    No
Skin Cancer: Yes    No    ( If Yes, Type: )
Cancer: Yes    No    ( If Yes, Type: )
Transplant: Yes    No    ( If Yes, Type: )
Family History of Melanoma: Yes    No    ( If Yes: Father Mother Brother Sister Son Daughter )
Other Conditions Not Listed Above:
Date of last Tetanus Shot:

Medication List

Do you take blood thinners? Yes    No
Medications you are currently taking:

Do you take Aspirin daily? Yes    No
Do you use Alcohol? Daily Socially Never
Smoking History: Currently Formerly Never
If smoking currently, please list frequency: